Is there evidence of intracranial injury or skull fracture? [checkbox name="variable_1" value="Yes|No |Unsure"]

Location of Impact: [text name="variable_1" default="sample text"]

Cause: [radio name="variable_1" value=" MVC|Athletics|Assault| Fall"]

Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? [checkbox name="variable_1" value="Yes|No |Unsure"]

Amnesia After S (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)?[checkbox name="variable_1|" value="Yes|No |Unsure|No Duration"] Loss of Consciousness: Did the athlete lose consciousness? [checkbox name="variable_1" value="Yes|No |Unsure |No Duration"]

Developmental History Developmental History O:Is there evidence of a forcible blow to the head? direct indirect Unknown

Is there evidence of intracranial injury or skull fracture? Yes No Unsure

Location of Impact:

Cause: MVC Athletics Assault Fall

Amnesia Before (Retrograde) Are there any events just BEFORE the injury that you/ person has no memory of (even brief)? Yes No Unsure

Amnesia After S (Anterograde) Are there any events just AFTER the injury that you/ person has no memory of (even brief)? Yes No Unsure No Duration Loss of Consciousness: Did the athlete lose consciousness? Yes No Unsure No Duration

A: 850.0 (Concussion, with no loss of consciousness) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plusevidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); no evidence of LOC (A5), skull fracture orintracranial injury (A1b). 850.1 (Concussion, with brief loss of consciousness < 1 hour) – Positive injury description with evidence of forcible direct/ indirect blow to the head(A1a); plus evidence of active symptoms (B) of any type and number related to the trauma (Total Symptom Score >0); positive evidence of LOC (A5),skull fracture or intracranial injury (A1b 850.9 (Concussion, unspecified) – Positive injury description with evidence of forcible direct/ indirect blow to the head (A1a); plus evidence of activesymptoms (B) of any type and number related to the trauma (Total Symptom Score >0); unclear/unknown injury details; unclear evidence of LOC (A5), noskull fracture or intracranial injury Other Diagnoses – If the patient presents with a positive injury description and associated symptoms, but additional evidence of intracranial injury (A 1b)such as from neuroimaging, a moderate TBI and the diagnostic category of 854 (Intracranial injury) should be considered